Post on 26-Oct-2019
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Pathophysiology of the kidney. Acute and chronic renal failureAcute and chronic renal failure
Blagoi Marinov, MD, PhD
Pathophysiology Department
Medical University of Plovdiv
Kidney physiology
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Nephronanatomy and physiology
Filtration
Reabsorbtion
Secretion
Functional renal syndromes
Hypertension – реноваскуларна, паренхимна, ренопривнаyp р у р р р р Edema – нефритни, нефрозни Osteodystrophy Altered diuresis Urinary syndrome Loss of ability to concentrate/dilute urine Altered homeostasis Hyper- hypocoagulability Hyper hypocoagulability Azotemia Lithogenesis
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Hypertension
R l Renoprival
Chronic hypoperfusionNephrectomy
Renovascularhypertension
Renoprival hypertension
HighRenin
LowRenin
Edema
Nephritic (decreased permeability)Primary Na+ retention (primary hypervolemic) Primary Na+ retention (primary hypervolemic) Sympathetic tone
RAAS
Secondary Na+ retention (membranogenous)
Nephrotic (increased permeability) Proteinuria Proteinuria
Oncotic pressure
RAAS
Sympathetic tone
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Р retention
Osteodystrophy
GFR
Р-retention
1, 25 Vit D3
Ca2+ SecondaryPTH
Ost
eocl
asts
Ost
eop
enia
Dem
iner
aliz
atio
n
Metabolic acidosis (Retention)
Osteodystrophy
Diuresis
Increased
Polyuria
Normal
Normuria
Decreased
Oliguria<0.5
Absent
Anuriay> 2 L/24 h 0.5-2.0 L/24 h L/24 h <0.15 L/24 h
Tubular dysfunction
HypotonicOmotic
normotonic and hypertonic
Glomerular hypo- and afunction
Dehydration(hypovolemia)
Hyperhydration(hypervolemia)
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Proteinuria and hematuria
Increased permeability of
glomerular
Overwhelmed (up to 1 g/24 h)or
S d
Microhematuria(>3 Ers)
Proteinuria(0.5 to 3.5 andglomerular
basal membraneSuppressed
tubular reabsorbtion>3.5 g/24 h)
Cilindruria
Proteinuria
Protein is not normally filtered at glomerulus and only trace amounts should be in urineonly trace amounts should be in urine
Microalbuminuria-20-200 mcg/min (30-300mg/24hr)
Proteinuria/albuminuria - >200 mcg/min (albumin is more specific for glomerular disease than protein)protein)
Consider : Ingestion of high-protein meal and vigorous exercise -> increase protein in urine
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Fe-deficit
Anemia
ЕРО
pp
ress
edth
rop
oes
is
ANEMIA
Fe deficitInhibitors
BONE MARROW
Su
eryt
Protoporphyrinhyposynthesis
Microangiopathic hemolysis
Lithogenesis
Hyper- normo-calciemia
Hypercalciuria
solubilizersin the urine
Overwhelmed metastability limit
of the urine
Spontaneous
Normocalciuria
Hyper-oxaluria
Hyper-ik i
или
crystalization of the urine solution
Lithogenesis
urikosuria
Hypocytraturia
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Nosology of the kidney
Glomerular
Tubulointerstitial
Toxic influences
Neoplastic processes
The kidney is an “innocent bystander” in many systemic diseases
Hypertension
Hypotension
Vasculitis
Thrombotic diseases/DIC
Systemic Lupus Erythematosis
Sickle cell anemia Sickle cell anemia
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Tubulo-interstitial diseases:
Cluster of abnormalities that, early on, affects the renal tubules and the interstitiumaffects the renal tubules and the interstitium
Spares the glomeruli and the blood vessels
TIDs can be divided into the following categories:
Ischemic: Acute renal failure, hypotension, blood loss, shock
Infections: Acute and Chronic pyelonephritis, viruses, parasites
Toxins: Drugs, analgesics, heavy metals (Pb) Metabolic: Urate, nephrocalcinosis, Oxalate Neoplasms: Multiple Myeloma Immunologic reaction: Transplant rejection
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Urinary Tract Infections
F:M ratio 8:1 Females 15-40 years of age
Infecting organisms from patient’s own flora
Bacteria reaches the kidney by: Ascending route (more common)
Blood borne (more dangerous) Blood borne (more dangerous)
Urinary Tract infections:
Most common organisms:G ti b illi (E C li i th t Gram negative bacilli (E. Coli is the most common)
Proteus, Klebsiella, Enterobacter, Mycobacteria (T.B)
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Predisposing factors for UTI:
Diabetes
P t Pregnanct
Obstruction (BPH, Tumors..)
Reflux
Immunosuppression
Instrumentation (Catheters, surgery...)( , g y )
Acute Pyelonephritis(Microscopic)
Neutrophils in the interstitium Neutrophils in the interstitium
Tubular damage (later)
Microabscesses in the interstitium
May lead to perinephric abscesses (Very painful)
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Pathogenesis of tubulointerstitial lesionsBacterial colonisation
(E. coli, Proteus, Clebsiela)
R flDifficult urine outflow
Reflux (urostatsis)
Contractile dysfunction of urinary ducts
Inefficient defences in urinary ducts
Tubulointerstitial invasion
Persistent bacterial inflammation
Suppressed macrophages
Resilient (L-form)bacteria
Hyperosmolality
Glomerulonephritis
Definition:
Renal disease characterized by inflammation of theRenal disease characterized by inflammation of the glomeruli, or small blood vessels in the kidneys.
Glomerulonephrites are categorised into several different pathological patterns, which are broadly grouped into non-proliferative or proliferative types. Diagnosing the pattern of GN is important because the outcome and treatment differs in different types.
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Normal glomerulus
Membranoproliferative glomerulonephritis
Pathogenesis of glomerulonephritis
Immunologic conflict
Towards own Ag(autoimmunity)
Similar to GBM bacterial Ag
(immune)
Constructed in situ(on site)
Circulating immune complexes
Towards implantedforeign (nonglomerular)
Agbacterial, viral
(immune)
p
Forcefully“Deposited”
or
Actively captured
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Nephrotoxicity of the complexes depends on:
Size – small to medium;
Ag-Ab avidity – high;
Clearance– low;
Electrical charge – polycationic; ect ca c a ge po ycat o c;
Valence - mono-, polyvalenticполивалентни;
Ratio – excess of Ag
Immune (autoimmune) inflammation
Ab mediated complement citotoxicity
Ab mediated cellular citotoxicity
Neutrophil and/or monocite attack
Proliferation of cells with growth potential –monocites, fibroblasts, mesangial cells
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Signs of glomerular damage are :
Increased permeability of glomerular basal membrane
Drop in overall glomerular filtration rate
Disfunction of JGA (Juxtaglomerular aparatus)
Glomerular-tubular disbalance
Acute glomerulonephritis
Most causes are infectious F ll t t l i f ti ( h Follows a streptococcal infection (when taking history ask client about recent infections)
Related to systemic diseases Lupus
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Signs and Symptoms
H t i d k b k i Hematuria: dark brown or smoky urine
Oliguria: urine output is < 400 ml/day
Edema: starts in the eye lids and face then the lower and upper limbs then becomes generalized; may be migratory
Hypertension: usually mild to moderate
Nephrotic Syndrome
Condition of increased glomerular permeability that allows larger molecules topermeability that allows larger molecules to pass through the membrane into the urine and be removed from the blood
Severe loss of protein into the urine
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Clinical Manifestations Of Nephrotic Syndrome Severe proteinuria
H lb i i Hypoalbuminemia
Hyperlipidemia
Edema
Hyptertension
Renal vein thrombosis may occury
May progress to ESRD without tx
A slow, progressive disease that can be caused by primaryA slow, progressive disease that can be caused by primary
Chronic Glomerulonephritis
A slow, progressive disease that can be caused by primary A slow, progressive disease that can be caused by primary ( ( NephroticNephrotic & Nephritic Syndromes) or secondary disorders & Nephritic Syndromes) or secondary disorders ( SLE, Good pasture's)( SLE, Good pasture's)
Typically develops asymptomatically over many yearsTypically develops asymptomatically over many years
Hypertension, Hypertension, proteinuriaproteinuria and and hematuriahematuria exhibited with exhibited with progression of diseaseprogression of diseaseprogression of diseaseprogression of disease
Late stages display uremic symptoms of Late stages display uremic symptoms of azotemiaazotemia, nausea, , nausea, vomiting, vomiting, dyspneadyspnea and and pruritispruritis
Leads to chronic renal failure (CRF)Leads to chronic renal failure (CRF)
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Renal failure
Failure to excrete nitrogenous waste andelectrolyte imbalanceelectrolyte imbalance.
Criteria for diagnosis (lab definition): Cr increase of .5 mg / dl. Increase in more than 50% over baseline Cr. Decreased in calculated Cr Clearance byDecreased in calculated Cr Clearance by
more than 50%. Any decrease in renal function that requires
dialysis.
A t l f il ARF i i l
Acute renal failure
Acute renal failure - ARF, now increasingly called acute kidney injury, is a rapid loss of kidney function.
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Acute renal failure
Spasm of v. afferens
Dilation of v. efferens
Decreased kidney permeability
Plugsdetrite, cilinders
Cellular tubular edemaIncreased tubular
pressure
Tubullar compression“glaucoma mechanism”
Tubulorrhexis(interstitial urine spill)
Definition:
Chronic renal failure
Progressive tissue destruction with permanent loss of nephrons and renal function
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Chronic renal failure
Biology – loss of working nephronso ogy oss o o g ep o s
Progress – increasing loss nephrons (%)
Stages – compensated, decompensated, uremic, comatous
Clinica syndromes – according to the main disease, complications, stage
Risk factors
Age > 60 years Race or ethnic background Race or ethnic background
African-American Hispanic American Indian Asian
History of exposure to chemicals/toxins History of exposure to chemicals/toxins Cigarette smoke Heavy metals
Family history of chronic kidney disease
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Chronic vs. Acute Renal Failure
Acute Renal Failure (ARF): Acute Renal Failure (ARF): Abrupt onset
Potentially reversible
Chronic Renal Failure (CRF): Progresses over at least 3 months
P t ibl d t h Permanent- non-reversible damage to nephrons
Causes of CRF
Diabetic Nephropathy
Hypertension
Vascular Disease
Polycystic Kidney Disease/Genetics
Chronic Inflammation
Obstruction Obstruction
Glomerular Disorders/ Glomerulonephritis
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Pathophysiology of CRF
Progressive destruction of nephrons leads to: Progressive destruction of nephrons leads to: Decreased glomerular filtration, tubular
reabsorption & renal hormone regulation
Remaining functional nephrons compensate
Functional and structural changes occur
Inflammatory response triggered Inflammatory response triggered
Healthy glomeruli so overburdened they become stiff, sclerotic and necrotic
Structural Changes of CRF
Epithelial damage Glomerular and parietal Glomerular and parietal
basement membrane damage
Vessel wall thickening Vessel lumen narrowing
leading to stenosis of arteries and capillaries
Sclerosis of membranes, l li d t b l
Healthy Glomerulus
glomeruli and tubules Reduced glomerular filtration
rate Nephron destruction
Damaged Glomerulus
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Functional Changes of CRF
The Kidneys are unable to:The Kidneys are unable to:Regulate fluids and electrolytesBalance fluid volume and renin-angiotensin
systemControl blood pressure
Eli i t it d th tEliminate nitrogen and other wastesSynthesize erythropoietinRegulate serum phosphate and calcium
levels
Four Stages of CRF
Reduced Renal Reserve (Silent): no Reduced Renal Reserve (Silent): no symptoms evident- GFR up to 50ml/min
Renal Insufficiency: ½ function of both kidneys lost- GFR 25-50 ml/min
Renal Failure: GFR 5-25 ml/min
End Stage Renal Disease: GFR less than 5 ml/min